View The Webinar: https://compliatric.com/continuous-compliance-2022-its-not-just-an-osv-prep-chapters-7-8/
Compliatric is excited to continue their “Continuous Compliance" Webinar Series based on the existing Health Center Compliance Manual and the most recently updated Site Visit Protocol. Each month, program requirements are reviewed to assist health centers in understanding the various elements and ensuring continuing compliance. Participants will be able to use these webinars to increase their knowledge of the requirements, and go one step further and utilize the program requirements to improve operational excellence.
This month’s webinar will focus on the following chapters:
Chapter 7: Coverage for Medical Emergencies During and After Hours
Chapter 8: Continuity of Care and Hospital Admitting
Webinar attendee takeaways will include:
· An understanding of the program requirements, which includes updates to the Site Visit Protocol
· Maintaining continuous compliance - not only based on a site visit
· Improving operational excellence for your Community Health Center
2. Chapter 7
Coverage for Medical Emergencies During
and After Hours
Chapter 8
Continuity of Care
3. Disclaimers
This presentation is not endorsed by Management Strategists
Consulting Group (MSCG)
This presentation is not endorsed by Health Resources Services
Administration (HRSA) or the Bureau of Primary Health Care
(BPHC).
Not employed by MSCG or BPHC
Independent Consultant who is contracted to conduct Operational
SiteVisits (OSV), provideTechnical Assistance and assist health
centers with preparation for their OSV
This information should not be considered legal advice
Confidentiality Notice: This document is confidential and contains proprietary information and intellectual property
of Infidium Healthcare Solutions. Neither this document nor any of the information contained herein may be
reproduced or disclosed under any circumstances without the express written permission of the aforementioned
party.
4. Purpose of the Compliatric Series
HRSA’s evaluation of compliance during COVID-19 continues via
Virtual Operational SiteVisits (vOSV)
Provides an overview of the health center program requirements
Provides updates to the SiteVisit Protocol and vOSV Process
Provides tips on “What to Expect”
Provides tips on “How to Prepare”
Provides a reviewer perspective
5. Purpose of the Compliatric Series
Compliance maintains HRSA funding
◦ Non-compliance can impact other Federal Programs (i.e., FTCA)
Continuous Compliance supports high performing health centers
◦ Eliminates the chaos of having to “prepare”
◦ Develops practices for operational excellence for the health
center
6. Agenda
Requirements for Compliance
Evaluation of Compliance
Maintaining Continuous Compliance
Clinical Reviewer Insight
Question and Answer Session
9. Requirements for Compliance
To assure continuity of care, the health center must have
the following:
Provisions for promptly responding to medical
emergencies during normal business hours; and
Clearly defined arrangements for promptly responding
to medical emergencies outside of normal business
hours.
10. Requirements for Compliance
Element a: Clinical Capacity for Responding to
Emergencies During Hours of Operation
The health center has at least one staff member trained
and certified in Basic Life Support (BLS) at each HRSA-
approved site on Form 5B to ensure the health center has
the clinical capacity to respond to medical emergencies
during normal business hours
11. Requirements for Compliance
Element b: Procedures for Responding to
Emergencies During Hours of Operation
The health center has and follows its operating
procedures for responding to medical emergencies during
normal hours of operation
Conduct staff training
Conduct mock drills
12. Requirements for Compliance
Element c: Procedures or Arrangements for After-
Hours Coverage
The health center has after-hours coverage procedures,
which may include formal arrangements with non-health
center providers or entities that ensure the following:
13. Requirements for Compliance
Element c: Procedures or Arrangements for After-
Hours Coverage
Coverage is provided via telephone or through face-to-
face contact by an individual with the qualifications and
training necessary to exercise professional judgement in
determining a patient’s need for emergency medical care
14. Requirements for Compliance
Element c: Procedures or Arrangements for After-
Hours Coverage
Coverage includes the ability to refer patients either to a
Licensed Independent Practitioner (LIP) for additional
consultation or to locations such as emergency rooms or
urgent care centers for further assessment/care as needed
15. Requirements for Compliance
Element c: Procedures or Arrangements for After-
Hours Coverage
Patients, including those with Limited English Proficiency
(LEP) are informed of and able to access after-hours
coverage, including being provided with information and
instructions on how to access after hours coverage in
languages, literacy levels and formats appropriate to the
patient population
16. Requirements for Compliance
Element d: After Hours Call Documentation
The health center has documentation of after-hours calls
and any associated follow-up resulting from such calls for
the purposes of continuity of care
17. Requirements for Compliance
BLS is a minimum requirement
Individual with BLS at each site can be a clinical or non-
clinical person
To ensure continuity of care, the health center must:
◦ Maintain documentation of after-hours calls and any
necessary follow-up
◦ Include the process used to address documentation
and continuity of care in the operating procedures for
after-hours coverage
19. Evaluation of Compliance
Review of Documentation
◦ Procedures to address emergencies during business hours and
after-hours
◦ Mock drills with staff
◦ Agreements with answering service/triage service
◦ Provider on-call schedules
20. Evaluation of Compliance
Review of Documentation (cont.)
◦ Documentation of BLS certification for any employees for up to
five sites
◦ Sample patient records of after-hours calls requiring follow-up
(3)
◦ Instructions/information provided to patients
◦ Methods for tracking and recording after-hours information (i.e.,
log)
21. Evaluation of Compliance
Staff Interviews
◦ Verification of process with Clinical Leadership
Placement of after-hours test call
◦ Can be completed at any time during the vOSV
◦ Reviewer will ask the point of contact how the call would be
handled if they were a non-English speaking patient
23. Maintaining Continuous Compliance
Review the following on a regular basis to ensure paper meets
practice:
◦ Operating procedures for handling medical emergencies during
normal business hours – Should not just be triage procedures
◦ Operating procedures for handling medical emergencies after
normal business hours
Conduct mock drills on a regular basis
◦ Chest pain, seizure, etc.
Test the after-hours line on a regular basis
Conduct routine chart audits to ensure appropriate documentation
of follow-up
26. Requirements for Compliance
Element a: Documentation of Hospital Admitting
Privileges or Arrangements
The health center has documentation of the following:
Health center provider hospital admitting privileges; and/or
Formal written arrangements between the health center and
one or more hospitals/entities in the service area for the
admission of health center patients
27. Requirements for Compliance
Element b: Procedures for Hospitalized Patients
The health center has internal operating procedures and
provisions in any formal arrangements with non-health center
providers/entities that address the following:
Receipt and recording of medical information related to the
hospital or ED visit
Follow-up actions by the health center, when appropriate
28. Requirements for Compliance
Element c: Post-HospitalizationTracking and
Follow-Up
The health center follows its operating procedures and formal
arrangements as documented by the following:
Receipt and recording of medical information related to the hospital
or ED visit
Evidence of follow-up actions by the health center, when appropriate
29. Requirements for Compliance
If providers have hospital privileges:
◦ Must be admitting privileges and not courtesy privileges
◦ Must routinely admit and round on health center patients
◦ Must be documentation of admitting privileges
◦ Frequently see admitting privileges for OB/GYN providers
30. Requirements for Compliance
If formal written arrangement(s) with hospital:
◦ One or more hospitals in the service area
◦ Must address patients across all lifecycles
◦ Must address emergency room and inpatient services
◦ Must address the exchange of patient information and continuity
of care
◦ Must address appropriate credentialing and privileging of
providers
32. Evaluation of Compliance
Review of Documentation
◦ Hospital privileges; and/or
◦ Hospital agreements with one or more referral hospitals
◦ Procedures to address tracking of ER visits and inpatient
hospitalizations, including patient follow-up
◦ Methods for tracking and recording ER visits and inpatient stays
◦ Samples of patient records for patients who have been hospitalized or
have had ER visits in the past 12 months (5-10)
Staff Interviews
◦ Verification of process with Clinical Leadership
34. Maintaining Continuous Compliance
Review hospital agreements on a regular basis to mitigate risk and
ensure compliance with frequently changing HRSA requirements
Review HospitalTracking Policies and Procedures routinely to
ensure paper meets practice
Review credentialing and privileging files routinely to ensure
appropriate documentation of admitting privileges
Incorporate hospital tracking metrics into the Quality
ImprovementWork Plan to monitor performance
36. Clinical Reviewer Insight
Ensure all points of contact for the after-hours process are aware a
test call will be placed
The after-hours process must address all services in scope and
ensure access to the Limited English Proficiency (LEP) population
◦ The reviewer will verify translation capability during the test call
The test call should NOT be placed prior to the start of the vOSV
The reviewer does NOT have to identify themselves as a site visit
reviewer when placing a call to the after-hours line
37. Clinical Reviewer Insight
Patient samples for after-hours coverage must be those that
require follow-up by the health center
Patient samples:
◦ Can be loaded into ShareFile with information redacted
◦ Screenshots can be viewed via GoToMeeting during the review
Industry standard call back time is 30 minutes
◦ Make sure the call back time is documented in the After-Hours
Policy and Procedure
38. Factors to Consider
Choose patient samples that clearly demonstrate follow up:
◦ Notification of patient hospitalization
◦ Receipt of discharge summary or hospital records
◦ Follow-up with patient (i.e., scheduling hospital follow-up visit)
Patient samples:
◦ Can be loaded into ShareFile with information redacted
◦ Screenshots can be viewed via GoToMeeting during the review
◦ Confirm the process during the pre-OSV call with the review
team
40. Additional Resources
Compliatric
https://www.compliatric.com/
HRSA Health Center Compliance Manual
Health Center Program Compliance Manual | Bureau of Primary Health
Care (hrsa.gov)
HRSA SiteVisit Protocol
Health Center Program SiteVisit Protocol | Bureau of Primary Health
Care (hrsa.gov)
HRSA Sampling Review Resource Guide
Health Center Program SiteVisit Protocol: Sampling Review Resource
Guide | Bureau of Primary Health Care (hrsa.gov)